Download Depression

“What is Wrong with the Patient?”
Part II
Assessment/Diagnosis
Dilemma & Running Debate
• Type 1 errors
(person has a mental disorder but is not diagnosed)
• Type 2 errors
(person does not have a mental disorder, but is diagnosed with one)
famous “Rosenhan” experiment (1972)
The aim of this study was to test the hypothesis that psychiatrists cannot reliably tell the
difference between people who are sane and those who are insane.
The study consisted of two parts with 8 pseudo-patients in 12 hospitals in 5 states.
Table 1 for Part 1: Responses of staff towards pseudo-patients’ requests—“labeling effect”
Response
Percentage making contact with patient
Psychiatrists
Nurses
Moves on with head averted
71%
88%
Makes eye contact
23
10
Pauses and chats
2
4
Stops and talks
4
0.5
Table 2 for Part 2: Judgment of all admissions as to the likelihood that they are pseudo-patients
193
Number of patients judged
Number of patients confidently judged as pseudo patients by
at least one staff member
41
Number of patients suspected by one psychiatrist
23
Number of patients suspected by one psychiatrist AND one
other staff member
19
Dilemma & Running Debate
These were the desperate questions that insurance companies raised
in 1970s:
Were patients in psychotherapy “medically ill”?
Was psychotherapy cost effective compared to alternative treatment methods?
How predictable were the costs given the frequency and length of treatment?
Irony
• Alan Stone, then President of the American Psychiatric Association
(APA) in 1976, concluded that social psychiatry and social activism,
“carrying psychiatrists on a mission to change the world, had brought
the profession to the edge of extinction.”
• During the DSM-III’s drafting in the latter half of the 1970s,
representatives from Blue Cross/Blue Shield and Aetna virtually
begged Spitzer and his task force to standardize the manual’s
diagnostic criteria so that insurers could separate legitimate mental
illnesses from non-psychiatric problems like “floundering marriages,
trouble raising children, and the difficulties in finding meaning in life.”
• As the insurance companies saw it, “Medical insurance should only be
asked to cover medical mental disorders. Insurance is meant to pay for
the sick, not the discontented who are seeking an improved lifestyle.
We need your help in differentiating between those who have mental
disorders and those who simply have a problem.”
Have the NIMH and psychiatrists lost their way?
Most of the well-trained, capable psychiatrists
of the 1970s no more wanted a patient base
composed of the seriously mentally ill than most of
the clinical psychologists and psychiatrists of today.
Mental health providers today, as then, favor the
“worried well,” those patients (“clients”?)
whose symptoms closely resemble people with
ordinary personal/life problems.
WHY?
These people: (1) have insurance coverage and/or sufficient financial means,
they (2) rarely trigger emergency calls on weekends, and
they (3) have relatively easily treated mental illnesses/disorders/problems
(THEY ARE VERY “affirming patients”)
Examples
Sexual Dysfunction in the United States Prevalence and Predictors
Edward O. Laumann, PhD; Anthony Paik, MA; Raymond C. Rosen, PhD
JAMA. 1999;281:537-544.
Objective To assess the prevalence and risk of experiencing sexual dysfunction across various social
groups and examine the determinants and health consequences of these disorders.
Design Analysis of data from the National Health and Social Life Survey, a probability sample
study of sexual behavior in a demographically representative, 1992 cohort of US adults.
Participants A national probability sample of 1749 women and 1410 men aged 18 to 59 years at the
time of the survey.
Main Outcome Measures Risk of experiencing sexual dysfunction as well as negative concomitant
outcomes.
Results Sexual dysfunction is more prevalent for women (43%) than men (31%) and is associated
with various demographic characteristics, including age and educational attainment. Women of
different racial groups demonstrate different patterns of sexual dysfunction. Differences among
men are not as marked but generally consistent with women. Experience of sexual dysfunction is
more likely among women and men with poor physical and emotional health. Moreover, sexual
dysfunction is highly associated with negative experiences in sexual relationships and overall wellbeing.
[sounds fairly ENVIRONMENTAL]
Conclusions The results indicate that sexual dysfunction is an important public health concern,
and emotional problems likely contribute to the experience of these problems.
ED: a common issue!
Do you have ED?
What Paxil CR Treats:
If your doctor has prescribed Paxil CR for you, you are now taking
an FDA-approved medication proven safe and effective for the
treatment of depression and panic disorder.
It Could Be Depression.
If you have felt persistent feelings of worthlessness and
hopelessness, or have an inability to feel pleasure or take
an interest in life, you may have depression.
Learn more about Depression.
It Could Be Panic Disorder.
If you have experienced repeated feelings of intense,
sudden terror or impending doom, racing or pounding
heartbeat or even chest pains, you may have panic
disorder.
Learn more about Panic Disorder.
It Could Be Social Anxiety Disorder.
If you have felt excessive, persistent fear and avoidance of
social or performance situations, accompanied by
sweating, shaking, tense muscles, or a pounding heart,
you may have social anxiety disorder.
Learn more about Social Anxiety Disorder.
Record Sales of Sleeping Pills Are Causing Worries
by STEPHANIE SAUL
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Disease Information:
Depression
More than 18 million Americans suffer from some type of depression, and one in eight persons need
treatment for depression during his or her lifetime. Depression is not a character flaw; it is neither a "mood"
nor a personal weakness that you can change at will or by "pulling yourself together."
OCD
Many healthy people can identify with having some of the symptoms of obsessive compulsive disorder
(OCD), such as checking the stove several times before leaving the house. But OCD is diagnosed only
when these activities take at least an hour a day, are very distressing, and interfere with daily life.
Bulimia
Bulimia nervosa is a disorder in which frequent episodes of binge eating are almost always followed by
purging (ridding the body of food). Purging can involve vomiting, taking large doses of laxatives or
diuretics, exercising compulsively, or fasting.
Panic Disorder
Panic disorder causes repeated attacks of intense fear in response to ordinary situations. This anxiety
disorder can cause physical symptoms like shortness of breath, a racing heart, trembling, dizziness, chest
pain, and stomach upset. A person having a panic attack may fear they are dying or "going crazy."
Learn about depression, obsessive-compulsive disorder, bulimia, and panic disorder in this section. The
more you know about these illnesses, the more you can do to manage and recover from them.
“Pfizer Launches 'Zoloft For Everything' Ad Campaign”
the ONION
Premenstrual dysphoric disorder (PMDD) isn’t just part of "being
a woman." It’s a real medical condition, and it causes real suffering.
PMDD is much more serious than PMS. If you have PMDD, learning
more about it can be the first step toward feeling better and getting
control of your life again.
Limits of Categorical Classifications of
Mental Disorders Based on Symptom-Driven Diagnoses
(1)
co-occurring/comorbidity is rampant
generally only about 12 truly unique, separate diagnostic entities/mental diseases
(2)
thus, assessment/diagnostic instruments often useful for multiple diagnoses
(3)
which is why several psychiatric drugs treat multiple disorders
(4)
structured disorders: hysteria, anorexia, MPD
gender, cultural eras, clinicians shape specific manifestations of underlying disorders
female: hysteria, anorexia/bulimia, more internalized disorders
male: substance-abuse disorders, aggression, more violent-oriented behaviors
Case Study: Alex McCarty